17 WITCHCRAFT RD - BPA EITYL-OF 1 . -.
PUBLIC PROPERTY \
+ all' DEPARTMENT
KINME "ONSCOLL
MAYOR
130 WAswwcrcw S7'REe-r*may.MAatnoiLst1-rs 01970
147. 976.743-MS•FAR.97d.7i0.9S46
APPLICATION FOR THE REPA_RL RENOVATION CONSTRUCTION
DEMOLITION. OR CHANGE OF USE OR OCCUPANCY FOR ANY EXISTING
STRUCTURE OR BUILDIN
1.0 SITE INFORMATION
i Location Name: 4 IV701V 10
/1jrlUl) N Building:
Property Address:
i -7 U
Property is located in a;Conservation Area Y/N Historic Distrlot Y/N
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2.0 OWNERSHIP INFORMATION
2.1 Owner of Land '
Name: Ak/ cw ` o mFN!)o (U C14
Address: 7
W-,�GHER q r-—7- I?L)
Telephone: 7 y / p 3 l 5
3.0 COMPLETE THIS SECTION FOR WORK IN EXISTING BUILDINGS ONLY
Addition jNew
sting
Renovation Number of Storienovated
Change in Use
Demolition stingApproximate year of Area per floor (sfovatedconstruction or renovation
of existing building Bdef Description of Proposed Work: 139Alrad/ lei
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TIV5T11LL iUr � </1'N�� 5 D iI(jg
Mail Permit to:
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aQ"Piii , -
What is the current use ��Building? H dwelling,how many units7�
Material of Building? 5 Asbestos?
WiU the Building Conform to Law? .
Archaect's Name ( )
Address and Phone
Mechanic's Name JS rti (u o L
Address and Phone
Construction Supervisors License# Duo 3�i 3 HIC Registration#
Estimated Cost of Project S
5 600 Permit Fee Calculation
Permit Fee$ /� Estimated Coat X$7IS1000 Residential
Estimated Cost X$11/$l000 Commercial
An Additional $5.00 Is added as an
Administrative charge.
Make sure that all fields are property and legibly written to avoid delays in processing.
The undersigned does hereby apply for a Building Permit to build to the above stated
specifications. Signed under penalty of perjury X
Date O
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